From the Editor

Getting bad grades vs. killing people

When I was in college I worried I would get bad grades if I didn’t learn everything in my courses. Grades meant a lot to me, as they did to most of us who eventually got into medical school. I hoped that I wouldn’t have to worry so much about grades once I was in medical school because, after all, I would already be in.

In fact, during medical school and residency, I stopped worrying about getting a bad grade if I didn’t learn enough. My new worry was: What if I don’t learn enough and accidentally kill somebody? Fortunately, everything in medical school got repeated multiple times until I learned what I needed to know.

Now that I am in practice, I am not as worried as I used to be that I might actually kill someone, although that is still in the back of my mind. What worries me today is learning all I need to know to help patients to the extent now possible. The faster the science of medicine changes, the more this concerns me.

We really do need to keep up with an amazing amount of information, don’t we? Almost any illness that affects a major organ system can lead to psychiatric symptoms. Pretty much any drug we give to treat psychiatric symptoms can affect other organ systems. Many psychiatric disorders can lead directly or indirectly to some somatic pathology. We need to keep up with general medicine, with new developments in diagnosis and treatment in psychiatry, and with the myriad interactions between medical and psychiatric conditions and treatments.

In this month’s issue of, Shaila Misri, MD, and Xanthoula Kostaras, BSc, bring us new insights into postpartum depression, a psychiatric disorder that in its most severe form can be fatal to the sufferer or her child, as recent headlines have reminded us all. I have distributed copies of “Postpartum depression: Is there an Andrea Yates in your practice?” to all the Ob/Gyns I’ve ever consulted to, and I have gotten much positive feedback (and more consultation requests) from them.

We also can learn about thyroid disorders and medication-induced cardiac arrhythmias, two medical conditions that also could kill our patients. I have incorporated into my practice the recommendations of W. Victor R. Vieweg, MD, on when to get an ECG on patients starting medications. And thanks to the insights of Richard Bermudes, MD, on thyroid disorders, I now feel more confident in interpreting minor elevations in physical hormone levels. In the past, I tended to order too many tests after detecting low-grade elevations, thus increasing my costs, turning up more false-positive results to follow up on, and unnecessarily frightening both myself and my patient.

The article by Dean Schuyler, MD, on cognitive therapy, lets us hone a potentially lifesaving tool for patients struggling with the chronic misery of dysthymia. Finally, the article on child and adolescent ADHD by Timothy Wilens, MD, Joseph Biederman, MD, and Thomas Spencer, MD, has been particularly helpful to me. After studying it, I concluded that I may have been underdiagnosing and undertreating this problem—in the process allowing patients to develop secondary morbidity. While to my knowledge my underdiagnosis and undertreatment of ADHD has not led to mortality among my patients, I am sure that depression and despair at getting inadequate answers and treatment could lead to a fatal outcome for some.

So welcome to another potentially lifesaving issue of. And keep those cards and letters (and emails) coming and let us know how we can help you. Write to, Quadrant HealthCom Inc., 110 Summit Ave., Montvale, NJ 07645, or e-mail us at current.psychiatry@dowdenhealth.com.

An early refill request for psychostimulants for your college-age patient

﻿Mr. R, age 18, who has been taking amphetamine/dextroamphetamine, 10 mg/d, twice a day, for attention-deficit/hyperactivity disorder since he was age 10, comes to see you shortly after beginning college asking to refill earlier than usual. He says his symptoms are worse since beginning college and he is finding it difficult to focus in class and keep up with the heavy course work. He says he has been taking an extra 10 mg when he “needs the extra boost.” He asks for an early refill and increased dosage. How do you proceed?

Switch to an extended release formulation and increase the dosage to 30 mg/d

Switch to lisdexamfetamine, 30 mg/d

Prescribe amphetamine/dextroamphetamine, 10 mg, on an as-needed basis

Tell Mr. R to take his current prescription as prescribed and discuss the dangers of stimulant abuse. Reassess his symptoms at the next visit.